Dina Balabanova Valeria Oliveira-Cruz Kara Hanson
London School of Hygiene and Tropical Medicine
Technical partner paper 9
Health Sector Governance and
Implications for the Private Sector
Health Sector Governance and Implications
for the Private Sector
October 2008
Dina Balabanova Valeria Oliveira-Cruz
Kara Hanson
Contents
ABSTRACT... 1
1. INTRODUCTION: WHY THE PRIVATE SECTOR MATTERS ... 3
2. PRIVATE AND PUBLIC SECTORS: DEFINITIONS ... 5
Box 1: Typologies of private sector providers in India ... 7
3. WHAT ARE THE BARRIERS TO PUBLIC-PRIVATE ENGAGEMENT? ... 9
4. GOVERNANCE IN THE HEALTH SYSTEMS: DEFINITIONS AND FRAMEWORKS ... 10
Governance: Definitions and dimensions ... 10
Governance frameworks... 12
Box 3: Elements of leadership and governance ... 12
Figure 1: Health system goals and functions... 13
Box 4: Principles of World Bank Group engagement on governance... 14
and anti-corruption... 14
Figure 2: The World Bank’s accountability framework ... 15
Governance failures... 15
5. HEALTH SECTOR GOVERNANCE AND THE PRIVATE SECTOR: AN ANALYTICAL FRAMEWORK... 16
Figure 3: Health sector governance and the private sector: An analytical framework ... 17
6. FORMS OF ENGAGEMENT BETWEEN THE PUBLIC AND THE PRIVATE SECTORS ... 21
The role of the government in relation to the private sector ... 23
Examples of country experiences ... 26
Examples of global actors’ efforts to strengthen the private sector ... 28
7. STRENGTHENING PUBLIC-PRIVATE ENGAGEMENT: WHAT CAPACITIES ARE NEEDED?... 29
Public sector capacities ... 29
Private sector capacities... 31
Box 5: Private not-for-profit coordination structures and dialogue with government in Uganda ... 32
REFERENCES ... 35 APPENDIX 1: HOW THE PUBLIC SECTOR ENGAGES WITH THE PRIVATE
INSURANCE MARKET IN INDIA ... 39 APPENDIX 2: HOW THE PUBLIC SECTOR ENGAGES IN PARTNERSHIPS WITH THE PRIVATE SECTOR IN UGANDA ... 43 APPENDIX 3: HOW THE PUBLIC SECTOR ENGAGES WITH PRIVATE
Abstract
The private sector plays an increasingly important role in the health systems of low- and middle-income countries. Scaling up the delivery of essential interventions to achieve international health targets is dependent on working with it. The “private health sector” includes an enormous diversity of actors, including providers, funders, and suppliers of physical and knowledge inputs for the health sector. The boundaries between the public and private sectors are often unclear as many private actors operate outside the regulatory framework of the health sector on an informal basis.
The private sector has received insufficient attention from national and global
policymakers because of a lack of information about its role. Public sector institutions often have a limited experience of engagement with the private sector due to suspicion compounded by a history of a lack communication, concerns about sustainability, and the complexity of interface required. They also lack the skills and competencies to engage with autonomous actors through more flexible and consensual approaches (as opposed to direct control).
This paper presents an analytical framework for conceptualizing the
governance/stewardship function within health systems and the role of government in the context of an expanded role for private service provision and financing. The paper begins by reviewing the approaches to defining and identifying its main functions, drawing on recent literature. Governance is increasingly recognized by the World Health
Organization and other global and national actors to be a fundamental health system function, and is a central part of their health sector and developmental strategies. Governance is a multidimensional concept, and there are normative, instrumental, and pragmatic models of stewardship. Governance failures, in health systems or in the wider society, have been perceived as obstructing progress toward international goals such as the Millennium Development Goals for health. These failures include the lack of a long-term vision and planning for essential interventions, the absence of a functional
regulatory framework, failure to address corruption, and limited efforts to assess performance. However, existing governance frameworks have not always been explicit about the significant role often played by private sector actors.
The paper then explores typologies of governance, with a focus on multiple forms of engagement and relationships between major public and private sector actors in achieving public health goals. In our conceptual model, the government interacts with the private sector at three different levels: by protecting the public interest, by working with the private sector, and by learning from each other. Possible roles for government (funder, regulator, health system steward) are identified in the context of a large or growing private sector. Indicators of progress are suggested. The framework recognizes that there are multiple public and private sector actors including individual consumers, civil
society, and, particularly in the context of aid-dependent low-income countries, donors. These actors are in complex interrelationships involving exchange of funding, skills,
by formal rules of engagement and informal rules, values, and attitudes. Maintaining engagement between actors—through dialogue, sharing information, and ensuring mutual accountability—is key to building and sustaining these relationships. The framework is applied to three case studies—of Afghanistan, India, Uganda—illustrating how
differences in context affect the nature of the stewardship function and the approaches that have been adopted to shaping the role of government in mixed health systems. Finally, the capacities required within both the public and private sectors to establish working models for multi-actor collaboration are considered.
1. Introduction: Why the Private Sector Matters
The private sector plays an increasingly important role in the health systems of low- and middle-income countries. It has received insufficient attention because of a lack of information about its role and significance, especially in the context of increasing external assistance. Public sector institutions often lack the skills and competencies to engage with non-state actors, as well as the motivation and interest to do so.
Since the 1990s, the World Bank has pioneered initiatives to draw on the private sector as a partner in reform of health financing and delivery, including proposing the introduction of user fees in public facilities in low- and middle-income countries and, more recently, reevaluating the role of the private sector in relation to contracting-out, social
reinsurance, and the corporatization of public hospitals (Preker A and Harding A 2003). Historically, some bilateral governmental agencies such as the U.S. Agency for
International Development have worked in close collaboration with the private sector, and have funded projects implemented by private sector organizations, both for-profit and not-for-profit. In the case of the U.S. Agency for International Development this
collaboration has been a reflection of one broader aim of U.S. foreign assistance policy, which is to expand free markets (USAID).
However, it is increasingly recognized that achievement of the Millennium Development Goals for health and other international targets is dependent on a significant scaling up of essential services. In many resource-limited settings, this has involved working with the private and voluntary sectors. It is now clear that the private sector cannot be ignored, and there is a need for proactive engagement with it, alongside the conventional public sector approaches. For instance, the global health initiatives established in the late 1990s and early 2000s (e.g., Global Alliance for Vaccines Initiative and the Global Fund to Fight AIDS, Tuberculosis and Malaria) have identified mechanisms to operate through private sector organizations in an effort to improve aid effectiveness and find new ways of working with recipient countries (Brugha R and Walt G. 2001; Brugha R, Starling M et al. 2002). This has led to a growing interest in incorporating private sector models and innovations such as results-oriented management.
The existence of a large private sector has multiple effects on the health care system and on households. A high level of direct out-of-pocket payments for private health care is often the cause of catastrophic health expenditure (Das and Hammer 2007). In settings where public health systems are weak and underfunded, patients and providers may enter informal transactions (also a form of unregulated private practice), which are a
commonly used coping strategy for underpaid health workers (Balabanova, McKee et al. 2004). Use of the private sector can lead to unaffordable and poor-quality care, especially for the poorest groups, who have limited alternative options (Das and Hammer 2007), although a lack of rigorous evidence makes it difficult to generalize across settings (Patouillard, Goodman et al. 2007). In many middle- and low-income countries, private sector use has been associated with an increase in multi-drug resistance for diseases
patient; a lack of standardized drug regimens; unregulated sales of TB treatment drugs; and insufficient patient follow-up (Shimouchi A 2001).
The nature of the private health sector in a country, and the way it has been influenced by historical patterns and changes, will determine what services are provided and the
patterns of use at any particular time. For instance, in most countries of the former Soviet Union, the private sector was formalized after the political transition. However, it
remains relatively limited apart from the pharmaceutical sector and outpatient care as its development is constrained by high entry costs, underdeveloped voluntary health
insurance, and a lack of trust (Balabanova D and Coker R. 2008). Most recently, in the context of globalization of trade in health services, there are growing concerns about medical tourism and its effects on the public sector, if increased demand for private services translates into competition with the public sector for scarce inputs such as human resources.
Most of the literature is focused on market failures affecting the private sector and the often negative implications for affordability, socioeconomic determinants of use, and quality. However, the private sector often offers an attractive alternative where public services are geographically inaccessible, unaffordable, and of poor quality, and it is often the only option acceptable and available to users. At the same time, there may be a range of skills, ideas, capacities, and comparative advantages within the private sector that can have positive effects on health outcomes. For example, some interventions may be more effectively delivered through existing private facilities, which the population may prefer to use (due to proximity or trust). The private sector may be used as a vehicle to meet the health needs of groups that are difficult to reach by other means such as communities in geographically isolated areas, those informally employed and not eligible for formal insurance, and groups facing stigma such as sex workers.
In theory, the effectiveness of health care delivery can be enhanced with use of innovative and flexible models and performance-based provider remuneration. Public-private partnerships may promote development and marketing of pharmaceuticals,
vaccines, and technologies more broadly benefiting low-income countries. A survey in 39 low- and lower-middle income countries showed that the availability of essential
medicines was on average 20 percent in the public sector and 56 percent in the private sector (WHO 2007). However, realizing these potential benefits is heavily dependent on a country’s context, most importantly the governance or public sector leadership. This includes the existence of appropriate legislation, regulatory capacity, safeguards, and planning processes to ensure that there are public sector alternatives to cover the poorest groups.
In many countries, the role of the government in leading the health sector is complicated by the multiplicity of health providers, facilities, and funding streams. The role of the private sector within a pluralistic health system, in situations where the public sector has limited capacity and resources, is not fully understood. The private sector may have complex relationships with multiple actors, at the level of service delivery (for example, though contracting), at the health policy level (health sector regulation), and at the wider
government level (business watchdogs). Its role is often complementary to the public sector, filling coverage gaps (e.g. the informally employed) and responding to local needs. Even where it is large and diverse, it is often insufficiently acknowledged in the long-term strategies and policies developed by ministries of health and global health actors. In fragile states there are semi-independent parallel health systems that often offer the only available source of care (as in covering refugees, rural area, or other excluded groups) and have few linkages with the “official” health system. In such situations, it is not clear who should lead the health sector, and by what means and how interventions and policies to achieve international targets (such as the Millennium Development Goals for health) can be planned and delivered. Yet another case is where the private sector has been historically almost entirely banned, as during the communist era, and subsequently has been legalized but with limited support for its development. The private sector may also compete with the public sector for resources and scarce inputs such as staff. The aim of this paper is to present a framework for conceptualizing the stewardship function within the health systems and the role of government in the context of an
expanded role for private service provision and financing. The paper explores the concept of stewardship and seeks to offer typologies of governance, with a focus on forms of engagement with the private and voluntary sectors. It identifies the key areas in which stewardship can contribute to supporting and monitoring the private sector to maximize its public health impact. The paper draws on recent literature published in peer-reviewed journals and unpublished documents, as well as on three country examples: Afghanistan, India, and Uganda. These case studies illustrate how differences in context affect the nature of the stewardship function and the approaches that have been taken in practice to shaping the role of government in mixed health systems. Cross-cutting issues and
relevant lessons are discussed.
2. Private and Public Sectors: Definitions
Before identifying the barriers to effective engagement between the public and private sectors, the terms “public sector” and “private sector” should be defined. From the perspective of political science, the public sector is defined as to include “[the] kind of activities public institutions carry out and how decisions are made and implemented by these institutions” (Lane JE. 2000). The public health sector is often understood simply as the Ministry of Health, but for the purposes of this paper, it includes, at the national level, (quasi-)independent regulators that are state-funded or state-owned and public payers such as independent state insurers (e.g., social insurance funds in Eastern Europe). Other government agencies such as business regulators, ministries of labor, ministries of commerce, and the judiciary may also have authority over issues relevant to private health sector operation, through functions such as licensing of health providers if set up as businesses or settling of litigation cases through courts of justice. At the international level, the public sector also encompasses international organizations such as the United
Nations and its specialized agencies (for example, the World Health Organization) (Reich 2002). All of these have the mandate to safeguard the public interest and improve health system effectiveness and outcomes.
The “private health sector” includes an enormous diversity of actors. These can be classified in several broad categories:
• Private sector providers. This group can often be the most visible part of the private sector because they have direct contact with users. However, there is considerable heterogeneity within this category, and the configurations of providers are specific to each context (see Box 1). For example, providers range from modern practitioners and certified health care professionals to traditional healers or other lay persons. Even in high-income country settings such as the United Kingdom, there is a wide range of practitioners providing therapeutic, clinical services, and alternative and spiritual treatments (Helman 1990). In low-income countries, private providers can provide both curative and preventive services, auxiliary services, and psycho-social support (Bennett 2005). Although such providers aim to treat physical and mental health problems or enhance health (as defined by the users), many of these fall
outside the health care sector and are regulated by other institutions. Homeopaths and other alternative practitioners are examples.
Private provision also comprises a range of institutions with different status—from largely not-for-profit nongovernmental organizations (NGOs) and faith-based organizations, to for-profit health care businesses—and may be organized as an individual or group practice.
• Financers, including private insurance, community-based health insurance, employer-based insurance, or direct employer financing of care.
• Private providers of inputs, including producers, procurers, and distributors of commodities relevant to the health sector. This includes physical inputs such as infrastructure, pharmaceuticals, and supplies such as condoms (Conteh and Hanson 2003) but also knowledge production (e.g., medical training institutions, production of information).
Private sector organizations can be funded through their own sources (from investment and profit, including from user payments), through government grants or subsidies, international aid grants, international donations (in kind), or a mix of these.
The private sector can be also formal or informal, where formality is defined in terms of recognition of health care providers by a country’s legal framework. For example, there are formally and informally employed staff categories within the private sector.
Informally employed staff may be recognized and sought by the clients they serve, but not by the legal framework of the country.Thus, in Uganda, while formal sector
providers comprise licensed private clinics, pharmacies, and drug shops, informal sector providers include unregistered private clinics, drug shops, market or itinerant vendors,
home-based providers, and traditional healers, who are not licensed but are favored and legitimized by communities (Birungi, Mugisha et al. 2001). Similarly, in the area of private finance, there may be cases where small-scale community insurers can be informally organized and not registered with government institutions, especially in the case where state capacity to regulate them is weak.
Box 1: Typologies of private sector providers in India
India has a diverse private health sector, which accounts for over 80 percent of outpatient visits (Peters D. and Muraleedharan VR. 2008 ); (Berman 2001). It can be classified according to its status (for-profit or not-for-profit, or formally or informally trained practitioners). • Formal, medically qualified, private for-profit providers (hospitals, individual and group
practices of general practitioners and specialists)
• Formal, medically qualified not-for-profit sector (hospitals, outpatient facilities, community-based programs)
• Formal providers qualified in Indian and other, non-allopathic system of medicine (hospitals, outpatient providers who have received formal training and are licensed) • Less than fully qualified practitioners (partially qualified and experienced practitioners of
allopathic medicine and other practitioners with limited or no formal training delivering mainly acute outpatient treatment and drugs)
Other classifications reflect the variable length and content of training for private providers and the qualifications obtained. Training programs last from six months to six years, and many providers lack formal qualifications (Das and Hammer 2007). The following groups can be identified:
• Those with an MBBS degree (bachelor of medicine and bachelor of surgery)
• Those with formal training in alternative medicine (Ayurvedas, homeopaths, Unani, and integrated systems doctors with degrees other than the MBBS degree)
• Those with little or no formal training (paramedics or “Registered Medical Practitioners,” generally referred to as “RMPs,” who are not registered with any recognized medical council, including the councils for alternative medicines.)
There is a third category that includes institutions that take a somewhat intermediate position between the public and the private sectors. These include organizations that share some of the characteristics of both the public and private sectors: consumer groups, NGOs, civil society, and some media organizations that are not part of government but seek to promote public interests (Reich 2002). This category also includes professional
organizations (e.g., physicians’ and nurses’ associations), which are often funded fully or partially from private sources and whose main objective is to safeguard their members’ interests, uphold professional ethics and identity (WHO 2006), and act as a platform for expressing collective views and positions, rather than to protect the public interest in general. In the absence of a long-established code of conduct, creating effective
professional associations for informal providers, for example drug sellers, as a means for promoting good practice, is likely to take a long time.
For example, the General Medical Council is an association comprising physicians working in the public and private sectors in the United Kingdom and is funded by its members’ contributions. It has an extensive mandate in licensing practitioners and considering malpractice cases, which in many other countries are the prerogative of the state, and its decisions can only be challenged through the courts. In other areas, its recommendations are advisory and reflect professional hierarchies and ethical concerns (e.g., on the appropriateness of particular treatments and rationing), with the state retains ultimate decision-making power.
Establishing strict boundaries between the public and private sectors can be difficult. They are often overlapping, especially in the area of financing and provision of care. For example, traditional notions of the public sector refer to government-owned and
government-operated providers that receive public finance to supply public services (Le Grand J. 2003). However, in systems where the purchasing and provision functions have been separated, governments may contract with the private sector to provide health services using public funds. Community-based insurance schemes may be used to finance care provided through the public health infrastructure (Bennett, Russell et al. 1995). Health workers can hold an appointment with a government facility and at the same time work either as independent health workers or as employees of a private practice (dual practice) (WHO 2006). They may collect informal fees from patients in public facilities or refer patients from public facilities to their private practices (McPake, Asiimwe et al. 1999). Other practices that challenge the boundaries between the two sectors include when public hospitals run private wards and charge for those services or when they allow physicians to treat private patients within public premises (Mills et al. 2002); and when commodities (drugs, condoms, and the like) purchased by the public sector are diverted into informal markets (Bennett et al. 2005). The reasons for this convergence between public and private can be sought in the weak health systems of many low and middle-income countries (due to long-term under-financing, conflict, or other reasons); traditions within the country; or societal expectations and ideologies, for example a belief that public institutions may benefit from market-oriented mechanisms and incentives (performance-related payment of providers, competition).
3. What Are the Barriers to Public-Private Engagement?
Many governments have a limited track record of engagement with the private sector because of a suspicion of the private sector compounded by a lack of information and a lack of history of communication (Bennett 2005). Many developing countries have traditionally followed a model of public provision and financing whereby ministries of health are responsible for hiring doctors, building hospitals, providing supplies, and paying for care. Often, separate management procedures, patterns of care, and information systems hamper effective collaboration between the public and private sectors. There are also concerns about the opportunity cost of resources channeled through the private sector to achieve health gains and improved efficiency in the short term, which could be applied more effectively to increasing the longer term sustainability of the public system. The vision and the ethos (an important element of governance) in the public and private sectors are often seen as incompatible, leading to a reluctance to seek public-private partnerships.
Another set of barriers to public-private engagement relates to the complexity of patterns of care, which may require prevention, treatment, and follow-up. This is particularly the case for chronic communicable and non-communicable diseases where delivery of effective care requires prolonged treatment, a combination of provider skills at different levels of the health system, and access to drugs and other commodities. Over the course of their treatment, users frequently move between the public and the private sectors, for example, to use different types of clinical skills and drugs. Providing integrated and continuous care is a challenge even in high-income settings, and even more so in under-resourced and fragmented health systems in low-income countries.
As discussed earlier, with the growing investment in the health sectors in developing countries, for example through the global health initiatives, resources are increasingly channeled both through ministries of health and through private and voluntary sectors. Efforts have been made to build on the expertise and capacity of the private sector and to establish working models for multi-actor collaboration. Evidence from research on the effectiveness of public-private partnerships in this area is still somewhat limited. However, there are positive examples emerging. In Tanzania, a Global Fund grant to support a voucher scheme for insecticide-treated nets for malaria prevention was channeled through a partnership between the government, NGOs, and the private retail sector: NGOs were to be contracted to do logistics, training, and promotion of vouchers, which are distributed by the public sector and redeemed from private shops (Hanson, Nathan et al. 2008).
4. Governance in the Health Systems: Definitions and Frameworks
This section examines briefly some of the definitions and frameworks used to
conceptualize governance and stewardship and examines their relevance to the private sector. The concept of governance is seen as fundamental by international actors, and it forms a central part of their health sector strategies and broader developmental strategies. Health sector governance is seen to be shaped by a country’s history, culture, values, institutions, and politics but also by the broader governance framework of a country. However, it is recognized that socioeconomic development does not lead to public sector development without purposeful investment, including strengthening the governance framework (Ahmad, Dreze J. et al. 1991).
Governance: Definitions and dimensions
In essence, governance influences how systems operate, what decisions are made, and what inputs are absorbed. Most frameworks incorporate a feedback loop—top-down action is followed by a response at the grass-roots level. For example, government regulations may be implemented and interpreted at the level of service delivery, and any problems should in theory feed back to the policy level and lead to revised policy. Although governance is usually analyzed in terms of the national level, it is increasingly considered in relation to the global level, reflecting political processes involving aid effectiveness and aid architecture. It has also underpinned the current debate and policy agenda on health systems strengthening.
Governance can be defined as the “action or a manner of governing,” government, the office or function of governing; or the authority, control, and steering (2006). It is a multidimensional concept related to a diverse range of ideas—systems of representation or citizen engagement, accountability, responsiveness, power and institutional authority, ownership, political stability, and the rule of law. Its dimensions include the political— how those in authority are elected, appointed, monitored; the economic—how public resources are managed and policies implemented; and the institutional—how citizens and the state itself relate to the society’s or public institutions. It is clear that each of the common definitions used emphasizes one of these dimensions to a larger extent; while some of the definitions emphasize the role of multiple actors, others take a more institutional approach. The definition of governance used by the United Kingdom’s Department for International Development explicitly includes the private sector in defining governance (see box 2).
Box 2: Definitions of governance
Several types of models of governance and leadership can be distinguished (drawing on Brinkerhoff and Bossert 2008):(Derick W. Brinkerhoff and Thomas J. Bossert 2008).
• Normative models, drawing on core societal values and norms, usually formalized through the legal and regulatory framework of the state. However, this model takes a top-down perspective and does not sufficiently reflect the complexity of regulation (as opposed to the “command and control” models) and of the behavior and motivation of front-line actors and their interactions.
• Instrumental models, focusing on intermediate health system objectives such as efficiency, effectiveness, private sector regulation, anti-corruption and good governance (e.g., the World Bank’s Worldwide Governance Indicators and Transparency International’s country ranking in corruption indices).
• Pragmatic models, emerging as a way of managing complexity at the micro/meso level by those who implement policies. It is argued that many international agencies tend to narrow down the concept of governance in line with their programmatic objectives (adopting normative/instrumental models) and that donor agencies (and governments) need to interact with local stakeholders to better operationalize the broader concept of governance, allowing it to be adapted to country-specific realities (Hyden 2003).
The United Kingdom Department for International Development: “We use the term governance to mean how the institutions, rules and systems of the state—the executive, legislature, judiciary and military—operate at central and local level and how the state relates to individual citizens, civil society and the private sector. We use government to mean the executive function at central and local levels. The political system or politics is the way power in the state is acquired and how people and groups inside and outside government influence the use of that power.” (DFID 2001)
The World Bank: “We define governance as the traditions and institutions by which authority in a country is exercised for the common good. This includes (i) the process by which those in authority are selected,
monitored and replaced, (ii) the capacity of the government to effectively manage its resources and implement sound policies, and (iii) the respect of citizens and the state for the institutions that govern economic and social interactions among them.” (The World Bank 2008)
The International Institute of Administrative Sciences: “The structure of institutions and societal norms by which authority is exercised for everyone's benefit at all levels, from local to global.” (GWG IIAS (The Governance Working Group of the International Institute of
Governance frameworks
Governance is identified as a core health system function by the World Health Organization in the 2000 World Health Report (WHO 2000), with the revised 2007 framework underlining its importance as cutting across health systems (WHO 2007). The World Health Organization considers the governance function of the health system as fundamental for all other functions (delivery, resources, financing), and has introduced the term “stewardship” (WHO 2000), later framed as “leadership” (WHO 2007). The concept of “leadership and governance” can be understood as a series of functions, both within the health system and beyond, requiring certain institutional capacities (see box 3).
Box 3: Elements of leadership and governance
In this framework, the government is responsible for system performance and achievement of policy goals. It emphasizes the “new” government roles given the complexity of actor and system design—roles in policymaking, information gathering, regulation and incentives (in the public and private sectors), and collaborative working (WHO 2000), going well beyond financing and provision of services, which have hitherto been considered main government responsibilities. The 2007 version of the framework is
• Policy guidance:
Formulating sector strategies and technical policies. Vision. Identifying the roles of public, private and voluntary sectors • Intelligence and oversight:
Generation, analysis and use of data on health systems goals and outcomes, especially for vulnerable groups
Monitoring the effects of policies and reforms; policy options • Collaboration and coalition building:
Across sectors in government and with external actors
• Regulation and incentives—“fairly enforced” • System design:
Ensuring a fit between strategy and structure and reducing duplication and fragmentation
• Accountability to the public. Transparency. Source: WHO 2007.
explicit about the main government responsibilities—to protect the public interest through engagement in political and technical actions—and gives added emphasis to global governance (harmonization and alignment between the multiple actors). The World Health Organization’s view of the role of the private sector has evolved in recent years. It recognizes that governments have to reconsider their role in the health system, in relation to new stakeholders that emerge through new policy processes (as when decentralization gives a more prominent role to regional authorities and private entities). It recommends engagement, stating that “…it is clear that governments do not have all the answers. Productive relations with the private sector and voluntary groups are both possible and desirable” (WHO 2007). However, governments should take the lead because they “have a much wider range of policy levers at their disposal” (ibid.).
Government adaptation to more pluralistic delivery models often implies the involvement of subnational authorities, rather than of private and voluntary actors. Although the World Health Organization’s leadership concept emphasizes the need to build coalitions with the private sector, the latter is still seen as an external actor that has to be brought on board once key national strategies are formulated. More generally, the private sector is less frequently mentioned under the other elements of governance as defined by the World Health Organization.
Figure 1: Health system goals and functions
The World Bank has defined governance in terms of six dimensions (The World Bank 2008):
• Voice and accountability
• Political stability and absence of violence • Government effectiveness
• Regulatory quality • Rule of law
• Control of corruption
Drawing on this framework, the most explicit linkage with health sector governance has been in the area of good governance and accountability. Good governance is seen as an essential precondition for development and as cutting across sectoral programs, including the health sector (Box 4).
Box 4: Principles of World Bank Group engagement on governance and anti-corruption
The World Bank has also developed an accountability framework representing the relationships between poor people, policymakers, and providers (World Bank 2003) (Figure 2). It has been influential in informing policy and practice and in further
conceptual development of the concept of governance (Bossert T 2007). Accountability is an aspect of governance, related to the health system goals of fairness and effectiveness, which can be also seen as indicators of health system performance (WHO 2000).
According to the Word Bank framework, poor people have two ways to ensure that services are accountable or responsive to them—directly through their choice of providers or, indirectly, by influencing provider behavior via elected officials. In some settings, people may receive public subsidies (for example, through vouchers) to access privately provided services that are deemed beneficial. The framework does not
differentiate between public and private providers, or depict how other policy actors are • Governance and anti-corruption are key for development—a
capable and accountable state can reduce poverty.
• Country ownership and leadership are more effective in the long term to improve governance. The World Bank seeks to strengthen, rather than bypass, national institutions.
• The World Bank still supports poorly governed countries/ innovative approaches.
• Engaging with a broad range of government, business, and civil society is key to governance reform and development outcomes. • Strengthening transparency, participation, third-party monitoring
in its own operations.
accountable to the providers. It also does not show the role of donors separately, implying that they would have an advisory role to the government.
Figure 2: The World Bank’s accountability framework
Source: World Bank 2003.
Governance failures
Governance has often been discussed in terms of governance failures, in health systems or in the wider society. A number of these have been perceived as particularly
problematic. These include a failure to effectively lead the health system with a long-term vision, and to prioritize, plan, and deliver the basic interventions required to improve outcome and make progress toward international goals such as the Millennium
Development Goals for health (Travis 2002). Governance failure can also be seen in an absence of a functional regulatory framework and accountability procedures and in limited efforts to assess health system performance. Failures to address corruption— including informal payments by patients that may deter access to care, kickbacks from pharmaceutical orders, or the sale of counterfeit medications—represent an increasing concern as they may undermine effective system functioning (Vian 2008).
In summary, although there has been a range of frameworks seeking to represent actors involved in health sector governance and the relationships among them, these
frameworks have not always explicitly demonstrated the significant role often played by the private sector. For example, the forms and mechanisms of government regulation and oversight in the private or public sector will be very different, requiring very different capacities.
5. Health Sector Governance and the Private Sector: An Analytical Framework
To deal with the considerable complexity of creating a governance framework that incorporates the role and significance of the private sector, we have first sought to identify the key actors and the relationships between them. The approach we take is normative, as with other similar frameworks, because it is extremely difficult to identify actors and relationships that are constant over time and across different contexts. This is even more so in low- and middle-income countries where capacity to maintain formal relationships may be limited.
It is now recognized that the main goals of health systems include health attainment for individuals and families, fairness, and responsiveness and that health systems are only effective to the extent they meet these objectives (WHO 2007). This implies that citizens and, specifically, health care users are central to any framework of health sector
Figure 3: Health sector governance and the private sector: An analytical framework
However, it is important to distinguish analytically between users as citizens and civil society (NGOs, patient groups, media, and so forth). Although the interests of citizens and the civil society may overlap (as when an NGO represents citizens or patient groups), this may not always be the case (as when an NGO’s main interests are to sustain its activities rather than to respond to need, which may involve scaling down some services). Both citizens and civil society actors have multiple relationships with each of the other major actors, relevant to the health sector—and these relationships are likely to be different for the two groups. For example, civil society may receive funding from donors and be accountable for it, and can also collectively monitor certain elements of the health system, while users can only submit individual complaints through government about the private sector. For simplicity, we designate the central place for the two types of actor but cannot graphically represent all possible linkages as they are different in each context.
For example, one possible way for the government to seek to improve health system accountability to citizens and users is by regulating the behavior of the private sector (see the India case study, in appendix 1). However, government’s limited ability to regulate private providers disadvantages users and also hampers the effective functioning of the health insurance market. Because providers can charge rates as they wish and because out-of-pocket is still the predominant mode of payment for hospital services, the ability of insurers to influence pricing by providers has been restricted. In Afghanistan, there has been a major shift in the government role from service provider to steward/financer contracting with NGOs to deliver essential health care (appendix 3). The attention to accountability and quality ensured through comprehensive monitoring and evaluation procedures (using a facility-based score card tool) has considerably improved access to basic health services in many areas (apart from remote areas or parts of the country with continued security concerns).
The other major actors include the government (which includes the Ministry of Health and other institutions with relevance to the health sector), the private sector (including the private and voluntary sectors), and in many low- and middle-income countries that are recipients of international assistance for health, donors.
All of these actors operate within the broader governance framework in a given country. It is based on the rule of law and the “rules of engagement”—which set the overall context for the way political processes work and different actors relate to each other (power, accountability, regulation). These rules determine how the health sector and other sectors operate, and how the health system is set up. However, there is also a set of informal rules (Bossert T 2007), values, and expectations within each society that govern the behavior of all actors. The laws, the “rules of engagement,” and the institutions need to have legitimacy and be respected by the citizens in order to be observed and
effectively enforced. Both formal and informal rules influence and frame all interactions between the actors. Over time, the informal rules and popular expectations change and influence the rules of engagement and rule of law through the political system; there is therefore a constant cycle of adaptation.
When describing the relationship between the different actors, we take as a starting point the role of government, which is often seen as the steward (WHO 2000) or the leader of the health system (WHO 2007), having a central role in ensuring good governance (Kaufman, Kraay et al. 1999). There is a recognition, mainly through the work of the World Health Organization and other global actors, that the government has the extensive responsibility for (a) defining the policy goals, (b) implementing the policies to meet these objectives, and (c) monitoring. However, we recognize that in practice this is not always the case—especially in countries where institutional capacity and financial resources in the public sector are severely limited (fragile states, post-conflict states, and the like). There may be situations where there is a well-developed and long-dominant private sector, and the government has only relatively recently sought to steer the health care system (India). In other cases, where the government is weak or nonexistent, it is the private and voluntary sectors (sometimes supported by donors) that are setting the rules for the government. While recognizing that the private sector may continue to be
influential and important in many settings, global actors have sought to invest the government with the role of key leader and actor shaping the health sector. The expectation is that most countries will eventually move toward a model in which government plays the stewardship role and, at a minimum, seeks to protect the public interest.
Policy goals may be set in consultation with the private sector, donors, and civil society (as in sector-wide approaches, also called “SWAps” or discussions of national strategic plans), but the government leads the process. This involves gathering information on needs and possible outcomes, setting priorities, and planning. Once the policy objectives are set, the government ensures that these are implemented through strategic oversight and monitoring. In cases where there is significant private sector involvement, donor involvement, or both, the role of government in monitoring implementation and
outcomes is even more important, through collecting information about the activities of the private sector and donors, mortality and morbidity patterns, and health service
utilization. The government is also responsible for regulating the private sector according to the legal and regulatory framework, both within the health sector and beyond. In cases where public funds are used to finance care provided by the voluntary or private sectors (as in contracting out services, or provision of direct subsidies), there is a need for clear financial accountability. In mixed public-private models, the government can provide other inputs such as infrastructure, staff, and guidelines (e.g., for community-based health insurance).
It is important to emphasize that the relationship between the government and the private sector is two-way— the public sector and donors may draw on skills available in the private sector such as management capacity, drug distribution systems, and access to marginalized groups. The private sector may benefit from publicly funded inputs (drugs, a trained workforce working in both the private and public sectors, physical infrastructure of health facilities) that can ultimately benefit the population and those accessing the health system.
The role of government in relation to donors includes accountability, particularly where donors have provided funding and technical skills. An important function of government in relation to donors is its responsibility for coordinating activities and ensuring that these are in keeping with national strategies and plans. On the other hand, donors can hold the government accountable (if they have provided funding) by obtaining information on the health sector and monitoring progress toward mutually agreed indicators. Another aspect of the relationship between government and donors within this framework is the
willingness of donors as a group to harmonize their policies and procedures, and align these with the nationally agreed plans of the government, as applied to the private sector and the civil society. Donors often can contribute technical skills, to benefit both the public and private sectors. Donors can also channel international assistance for health (monetary and in-kind) directly to the private sector and civil society, to provide a wide range of services.
The private sector is accountable to the government in terms of regulatory requirements and other specific agreements, including being legally registered, maintaining quality standards, ensuring safeguards against abuse are in place, and the like. It can be also accountable to donors where the donor is providing the funding and technical assistance. As discussed above, the private sector, ideally, provides information about its activities to the government and to donors if relevant (e.g., population served, outcomes, utilization data disaggregated according to pre-agreed criteria, user characteristics) that could feed into national data collection systems, to help identify gaps in coverage and plan for the scaling-up of services. The private sector can also provide other inputs that can benefit the public sector, for example personnel trained by NGOs or private educational establishments who can then be employed in the state sector, or certain skill sets not available in the public sector such as management expertise.
A critical role that is specific to the private sector is its ability to influence the other actors through lobbying and participation in the policy process, for instance by gaining favorable public exposure in the media: this is often played out in the relationship with the government, with donors, and, to a lesser extent, with civil society.
As noted earlier in this section, citizens may have multiple relationships with any of these health system actors, depending on the setting, health system setup, and formal and informal rules. In relation to citizens, the government ensures that policy goals are formulated and met, through oversight and monitoring. This involves health system– specific goals such as providing responsive services (in terms of patient health needs, demand) but also enforcing wider legal rights such as the right to redress in cases of discrimination or malpractice. In most cases, citizens can hold the government accountable through the political system (voice/vote) or through regulatory channels (complaints, exiting the system). The private sector offers services to the population (financial, treatment, inputs such as drugs). When deciding to access the health system, users exercise choice in relation to which private facility they attend and what services they pay for.
As discussed above, civil society may have interests that closely overlap with the interests of individual users and their families, or in other cases, it may have characteristics similar to voluntary sector entities that are part of the private sector. Certainly, it is agreed that the government must ensure a fair democratic process and create an enabling environment for the existence of civil society organizations, even provide funding (e.g., national press, watchdogs). Civil society organizations may receive information, funding, and other inputs from the private sector and donors, which can then demand feedback and accountability. On the other hand, civil society can provide skills and information to the other actors in the framework and act as an independent monitor of governance issues in the health sector (specifically in relation to non-state actors), and thus have considerable influence over the policy agenda and public accountability. Figure 3 above shows that, in most relationships, the key element of governance is maintaining engagement—through dialogue, the sharing of information, and
all the government, create and maintain spaces for this dialogue and make sure that flows of communication are sustained.
6. Forms of Engagement between the Public and the Private Sectors
Having discussed the main building blocks of the health sector governance framework, we now examine the forms of engagement and the functions for the public sector that these forms of engagement require. The framework helps to define the role of the government in health sector governance vis-à-vis other actors involved, and identify the range of actions required.
In our conceptual model, the government interacts with the private sector at three
different levels: by protecting the public interest, by working with the private sector, and by learning from each other (see the table below). The relationship between the
government and private sector actors can be placed on a continuum moving from a minimum level of interaction to a higher degree of engagement between the two sectors. Protecting the public interest represents the minimum level. At this level, the government defines and enforces the rules of engagement; and ensures an overall good governance environment. Within this context, it sets the policy goals in the health sector with a view to ensuring that basic services are available to the population; it establishes mechanisms of risk protection for the poor and vulnerable; and it ensures that required resources are generated and allocated. Finally, the government stewards the health sector toward achieving the policy goals that have been set. At this level, there are minimum forms of engagement with the private sector that the government needs to accomplish to protect the public interest. These are regulating and stewarding. When regulating the private sector, the government must set minimum standards for quality of services and medical education, enforce these standards through monitoring and sanctions, and legislate against malpractice. As part of its stewardship role, the government is likely to require data from the private sector (e.g., utilization statistics, some process and outcome indicators) for monitoring of the sector as a whole.
As government interaction with the private sector expands toward working to increase coverage through affordable mechanisms and reducing fragmentation, additional forms of engagement may take place. In relation to financing, the government may consider
contracting with private organizations to provide specific health services (for example, the recently launched National Rural Health Mission in India provides for contracting with private practitioners to fill the vacant posts in public facilities). Alternatively, it may provide tax credits to reduce health care costs for small employers (Hess C., Schwartz S. et al. 2008). As leader of the sector, the government can involve the private sector in making decisions on health policy objectives and strategic plans; provide information to providers (e.g., treatment guidelines) and users (e.g., health information and promotion);
A higher degree of interaction takes place when both sectors learn from each other’s experiences by collaborating on common activities. In its stewardship role, the government can foster greater interaction by creating spaces for communication and exchange that can allow for the development of joint activities. These can lead to opportunities for both sectors to learn from each other (e.g., in relation to management models, service delivery approaches).
We are considering here the scenario of a benevolent government that is interested in improving the health and well-being of its citizens and that has the basic resources at its disposal to do this. However, as mentioned earlier, there are situations in which the private and voluntary sectors can form alliances and choose not to engage with the government in order to protect public interest (failed states, war zones, areas with a high level of corruption in the public domain); this collaboration is also accommodated by our framework (figure 3 above—relationships between the private sector, donors, and
NGOs). It could be argued that this form of alliance does not preclude efforts to build government capacity in the medium or long run.
The role of the government in relation to the private sector
Levels of Public Engagement with the Private Sector PROTECTING the public interest
To define and enforce the “rules of engagement” and uphold the rule of law
To ensure good governance To set health policy goals:
To ensure basic services are available and equitably distributed
To establish risk protection mechanisms To ensure resource generation
To be an effective steward of the health system To ensure responsiveness to the population
To be accountable for health system performance (policy implementation and service delivery)
WORKING with the private sector
To scale up interventions and improve quality To reduce fragmentation and achieve synergies To foster collaboration and coalition building between the public and private sectors To recognize professional organizations or self-regulatory bodies to facilitate the progress toward common policy goals
LEARNING from each other
To ensure that the public and private sectors, as well as the civil society, collaborate and learn from each other’s experience
Forms of Public Engagement with the Private Sector Regulation
- Law enforcement (ensuring compliance, e.g., compliance with international health regulations)
- Setting minimum standards for quality/ legislation against malpractice - Setting minimum Financing - Subsidies (through tax, grants, in-kind, investment, credit, loans, concessions) - Obtaining
credit from the private sector to expand
Stewardship
- Formulating and appraising sectoral strategies and technical policies involving the private sector
- Involving non-state actors in making decisions to achieve overall health policy objectives (e.g., priority setting, planning, service delivery configurations) with clearly defined roles
- Provision of information: (Harding A and Preker A 2003)
- to users: on consumers' rights and health information and promotion, on private sector performance (quality and patient safety data) to allow greater consumer choice (Hess C., Schwartz S. et al. 2008)
- to providers: treatment guidelines/protocols, recommended drugs, evidence-based information
- Coordination of epidemic and emergency preparedness and response, and surveillance for diseases of epidemic potential
- Promotion of an effective balance of services (e.g., between treatment and prevention) and reduction of incentives toward non-essential treatment
private sectors - Strengthening public accountability and citizens’ voices, transparency, e.g., through: - Use of intermediaries to introduce consumer safeguards (such as the Consumer Protection ACT (COPRA) in India) (Kaufman et al. 1999) - Licensing - Accreditation (mandatory) - Creating a legal basis
for the existence of self-regulatory bodies in the private sector
Finance Initiative) - Contracting out - Social marketing - Use of vouchers - Franchise
and outcomes; monitoring system’s performance and the effects of policies, both in the public and private sectors); knowledge generation and translation into policies
- Anti-corruption measures - Preventing the public interest
from being captured through lobbying etc. (e.g., government’s ability to resist pressure from the private sector)
responsibilities for workforce regulation to medical associations) - Training of health workers (continuous education, supervision)
- Learning from innovative models of service delivery, financing, management, manufacturing, procurement
- Frequent communication, supervision, and feedback mechanisms between government, private sector, and civil society
- Facilitating change through the use of policy advocates: participative, bottom-up approaches involving community, managers, and staff
- Participation at global-level initiatives, including a focus on the private sector
Indicators of Progress - Regulatory framework
for operation of a private health sector (existence of legal instruments—specific to the health sector or via general business regulation, trade, commerce) - Dedicated - Mechanisms for private sector finance (e.g., established public-private partnerships) - Levels of financing
- Platforms for effective public-private collaboration (within the policy process, e.g., annual joint review meetings) - Joint initiatives in place (e.g., training)
- National strategic plans and technical policy documents - Health Management Information Systems
- National Health Accounts - Annual performance reports - Research and studies
- Treatment protocols and guidelines
court/justice system (e.g., health consumer forums, tribunals) - Medical audits - Medical malpractice insurance schemes - Consumer redress mechanisms at the facility level (e.g., complaints boxes) - Consumers’ charter - Information, education and communication materials
Clear boundaries between the different levels of public engagement with the private sector are unlikely to be found in real country contexts. Governments may be working with the private sector, for example by providing subsidies to NGOs, without achieving a minimum level of effective enforcement of rules and regulations (as in Afghanistan). The problem of non-compliance with existing rules may prompt governments to seek
alternative mechanisms to regulate the private sector, which could be seen as an
expanded form of engagement. But these may also be limited in their scope to contribute to improvements. In India, for example, in spite of there being several and comprehensive legal instruments to regulate the private health sector, including a dedicated court system (Consumer Forums) that offers faster processing of cases through the Consumer
Protection Act as compared with the regular courts, the ability of the government to enforce the law and deal with increased public demand for legal services is weak—as exemplified by the experience of Consumer Forums, which struggle with insufficient staff and lack of infrastructure (Peters D. and Muraleedharan VR. 2008 ). In addition, the Consumer Forums address only the areas where consumers complain against a deficiency in service by the health providers, and do not address failure to comply with government regulations, limiting their utility to regulate the private health sector.
Examples of country experiences
More detailed examples of country-level experiences in how government engages (as a regulator, funder, and steward) with the private sector are discussed in this section, based on case studies of India, Uganda, and Afghanistan. The Indian case study, in appendix 1, focuses on regulation and the development initiatives of a fast-growing private insurance market. Public-private partnership with the government providing subsidies for faith-based NGO service providers is the theme for the Ugandan case study in appendix 2. Finally, the Afghan experience of contracting with NGOs to provide health services is illustrated in appendix 3.
The country examples indicate that governments can successfully engage with the private sector in a number of ways and in a range of different contexts. As a steward and funder, in each setting government collaborated with private sector organizations to increase coverage and improve the geographical spread of services. This was possible in India as state governments acted as buyers of health insurance packages covering vulnerable population groups. In Uganda and Afghanistan, private providers received government subsidies or were contracted to provide services in remote and under-served areas.
Governments used innovative models such as contracting to outsource service delivery or administrative capacity. In India, the government contracted out expert services from third-party administrators to support its insurance activities in the health sector. In Uganda and Afghanistan, where the governments lacked sufficient financial resources, donors were influential in supporting government efforts to strengthen the policy process and capacity to collaborate with private providers. In addition to providing financial resources, donor support for country-level aid coordination mechanisms was also beneficial in fostering a synergizing environment for government and private sector interaction, as was the case in Uganda. In Afghanistan, donor funding enabled integration
of what was a fragmented system of private providers. Contracting with NGOs resulted in coverage of 77 percent of the population in all regions of the country.
These country examples also show that there are a number of challenges with regard to government engagement with the private sector. For example, a common problem included the lack of sufficiently developed information systems that allow the inclusion of private sector data. Although the data repository (created from the insurance
perspective) in India provides some demographic information on insured persons and claims processing data, it does not include information on quality of care provided to the insured, or on outputs and outcomes. In Uganda, the exclusion of private for-profit providers from routine information systems hinders the scope of government planning and efforts to evaluate the health sector as a whole. When directly financing the sector— for example, by contracting with private providers—governments have greater leverage and can require reporting from the private sector to include various types of information, including quality measures (Hess C., Schwartz S. et al. 2008), and it can also build in financial rewards for improvements.
When introducing regulatory measures and developing financial and other initiatives involving the private sector, it is important to pay close attention to the whole cycle and not only the design phase—including management (with clear administrative
responsibilities) and close monitoring. For example, cost control mechanisms need to be built into the design and implementation of insurance plans, which prevent misuse or overutilization of benefits with implications for the long-term sustainability of the plans. A possibility is that governments establish legal requirements for public reporting to support consumer choice by allowing open access to standardized performance measures for private providers. Such a requirement may work as an incentive mechanism for providers to increase quality and efficiency (lower costs) because they are at risk of competition from other providers with higher ratings who can attract more consumers (Galvin 2003). However, these require strong government capacity to develop
standardized measures and make these available to the public in a way that is both
accessible to consumers and useful for clinicians; their development involves an intensive process of expert consultations on the choice of measures and on how best to package the information for consumers, and an intensive process of agreement with private providers. Other challenges that can be seen in the country examples:
• Lack of skills at subnational levels of government to work with private providers (e.g., the inability of district politicians to recognize the role of private providers in Uganda, and insufficient stewardship capacity in Afghanistan)
• Unpredictability of external funds (e.g., risk of decreased aid levels in
Afghanistan as conflict subsides and maintenance of budgetary ceilings by the government in Uganda preventing an increase in donor funding)
• Effects of competition (changes in the nature and structure of the health care market, including the possibility of greater use of public facilities).
Examples of global actors’ efforts to strengthen the private sector
Globally, there has been considerable experience in collaborating with the private sector. For example, the U.S. Agency for International Development works with more than 300 private voluntary organizations based in the United States that operate in various
developing countries. The supplies (commodities, services) used by agency-funded projects, however, tend to be earmarked for American contractors (over 3,500 American companies work with the agency). This is often criticized for not allowing the
strengthening of local markets but instead reverting as benefits to the American economy (Azfar O. 2002).
More recently, a number of global health initiatives that provide grants to developing countries have made deliberate efforts to engage the private sector in their decision-making processes. In the case of the Global Fund to Fight AIDS, Tuberculosis and Malaria involvement of the private sector is demonstrated by membership of private sector organizations (for-profit and not-for-profit organizations) on the board of the fund (GFATM n.d.). In addition, fund recipients are required to have established a Country Coordinating Mechanism which should include private sector representatives.
Other global health initiatives involving collaboration between the public and the private sectors have been created with the aim of fostering the development and distribution and sometimes the donation of health or health-related products (e.g., drugs, vaccines, and diagnostic tools). Both types of global health initiatives (grants or commodities oriented) have contributed to international health by bringing what were “neglected” health
problems into the national and international agendas; raising new funds for these health issues, fostering research and development, enhancing access to health interventions among the poor, improving health services capacity, and creating norms and standards at the international level (Buse K and Harmer A 2007). However, the authors also point to negative effects exerted by these initiatives, namely, distorting the national priorities by imposing their own agendas onto recipient countries, allowing some stakeholders greater say than others within decision-making structures, failing to abide by governance
principles such as transparency and dealing with conflict of interest, decreasing the “public” nature of global health initiatives, and failing to compare systematically the costs and benefits of public or private models.
Another example of international donor engagement with the private sector but operating at the country level is the experience of Output Based Aid run by KfW (German
Development Bank). In Kenya, KfW supports a voucher scheme that is considered to have achieved good targeting of the poor, produced a good health impact (in terms of maternal mortality and contraceptive prevalence), supported the private sector (by including independent midwives), and created competition between public and private facilities. It is, however, a vertical approach in that it covers only safe motherhood and family planning, and up-scaling to other services is technically problematic. The management of the voucher scheme is set up as a parallel structure to the existing government structures because of fears that efficiency and transparency of resource management by government institutions are lacking. Nevertheless, there is a long-term
